Ramipril

Overview

Ramipril, sold under the brand name Altace among others, is an ACE inhibitor type medication taken by mouth used to treat high blood pressure, heart failure, and diabetic kidney disease. It can also be used as a preventative medication in patients over 55 years old to reduce the risk of having a heart attack, stroke or cardiovascular death in patients shown to be at high risk, such as some diabetics and patients with vascular disease. It is a reasonable initial treatment for high blood pressure.[1–4] WP

Common side effects include headaches, dizziness, fatigue, and cough. Serious side effects may include liver problems, angioedema, kidney problems, and high blood potassium. Use in pregnancy and breastfeeding is not recommended. It is an ACE inhibitor and works by decreasing renin-angiotensin-aldosterone system activity.[1][5] WP

Ramipril was patented in 1981 and approved for medical use in 1989. It is available as a generic medication. In 2023, it was the 211th most commonly prescribed medication in the United States, with more than 2 million prescriptions.[6–9] WP

Uses, dosage and effects

Medical uses

Medical uses include: WP

• High blood pressure (Hypertension) WP
• Congestive heart failure[10] WP
• Following heart attack in people with evidence of heart failure WP
• People over 55 years at high risk: prevention of heart attack, stroke, cardiovascular death, or in need of revascularization procedures WP
• Prevent the onset and/or delay the progression of diabetic kidney disease, with or without proteinuria. Randomized trial evidence suggests that a maximum tolerable dose prevents cardiovascular events and death in patients with diabetic kidney disease.[11] WP

Risks and side effects

Contraindications

Contraindications to its use include volume-depleted patients, a history of angioedema while on an ACE inhibitor, pregnancy and hypotension.[1] WP

People should not take ramipril (or any ACE inhibitors) if they have hyperkalemia. It is also recommended to avoid using salt-substitutes as this can further increase potassium levels in the blood.[1] WP

Ramipril can be considered in patients with bilateral or unilateral significant renal artery stenosis (RAS). An early rise in serum creatinine above baseline is expected after initiation of therapy with Ramipril, however, monitoring serum biochemistry and renal function after initiation is crucial. Treatment with Ramipril in some patients with significant narrowing in both kidneys can increase serum creatinine concentration (measured in the blood test), which returns to baseline upon therapy cessation.[12][13] WP

Adverse effects

• Shakiness WP
• Dry cough WP
• Dizziness and lightheadedness due to low blood pressure WP
• Fatigue, especially in the early stages WP
• Mouth dryness in the early stages WP
• Nausea WP
• Fainting WP
• Signs of infection (e.g., fever, chills, persistent sore throat) WP
• Chest pain WP
• Neutropenia (low white blood cells) WP
• Impotence (erectile dysfunction)[14] WP
• Hyperkalemia WP

Serious allergic reactions to this drug are unlikely, but immediate medical attention must be sought if they occur. Symptoms of a serious allergic reaction include, but are not limited to a rash or swelling of the face, mouth, tongue, or throat. In extreme cases, ramipril may lead to potentially fatal liver problems. WP

Pharmacology

Mechanism of action

ACE inhibitors inhibit the actions of angiotensin converting enzyme (ACE), thereby lowering the production of angiotensin II and decreasing the breakdown of bradykinin. The decrease in angiotensin II results in relaxation of arteriole smooth muscle leading to a decrease in total peripheral resistance, reducing blood pressure as the blood is pumped through widened vessels. Its effect on bradykinin is responsible for the dry cough side effect. WP

Ramipril, a prodrug or precursor drug, is converted to the active metabolite ramiprilat by carboxylesterase 1. Ramiprilat is mostly excreted by the kidneys. Its half-life is variable (3–16 hours), and is prolonged by heart and liver failure, as well as kidney failure. Peak effect occurs between 3 and 6 hours after dosing, with approximately 50% of this effect retained after 24 hours.[15][16][17] WP

Research

Research

The 2001 Heart Outcomes and Prevention Evaluation trial seemed to show ramipril possessed cardioprotective qualities which extended beyond its qualities as an antihypertensive. However, the trial and the interpretation of its results have been criticised.[18][19][20] WP

The Acute Infarction Ramipril Efficacy (AIRE) trial showed a 27% reduction in mortality for patients receiving ramipril for chronic heart failure following a myocardial infarction.[15][21] WP

Ramipril was found to have similar results as telmisartan, an angiotensin II receptor blocker.[22] WP

Legal status

Us patent

The compound was protected by a patent which was assigned to the German pharmaceutical company Hoechst AG (since merged into Aventis) on 29 October 1991. The patent was scheduled to expire on 29 October 2008. On 11 September 2007, in an appeal by the Indian company Lupin Ltd., the United States Court of Appeals for the Federal Circuit reversed a district court trial verdict and found that Aventis's patent on ramipril was invalid for "obviousness", opening this drug to generic manufacturers.[23] WP

Chemistry

Formula

C23H32N2O5 PC

CAS number

87333-19-5 PC

Molar mass (g/mol)

416.5 PC

IUPAC name (computed by PubChem)

(2S,3aS,6aS)-1-[(2S)-2-[[(2S)-1-ethoxy-1-oxo-4-phenylbutan-2-yl]amino]propanoyl]-3,3a,4,5,6,6a-hexahydro-2H-cyclopenta[b]pyrrole-2-carboxylic acid PC

SMILES

CCOC(=O)[C@H](CCC1=CC=CC=C1)N[C@@H](C)C(=O)N2[C@H]3CCC[C@H]3C[C@H]2C(=O)O PC

InChIKey

HDACQVRGBOVJII-JBDAPHQKSA-N PC

PubChem CID

5362129

Harm reduction information

No harm reduction data is on file for this compound yet. That means no dose, timing or combination data from PsychonautWiki or TripSit. Please don't guess a dose from similar compounds. If you have taken it and feel unwell, contact emergency services or a poison control center.

User reports

Pop culture

No references added yet.

Sources

1. Other Ramipril Monograph for Professionals. 10 July 2026
2. Journal / agency Yusuf S, Sleight P, Pogue J, Bosch J, Davies R, Dagenais G. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The New England Journal of Medicine. January 2000. doi:10.1056/NEJM200001203420301 · PMID 10639539
3. Journal / agency HOPE study investigators. Effects of ramipril on cardiovascular and microvascular outcomes in people with diabetes mellitus: results of the HOPE study and MICRO-HOPE substudy. The Lancet. January 2000. doi:10.1016/S0140-6736(99)12323-7
4. Journal / agency Savarese G, Costanzo P, Cleland JG, Vassallo E, Ruggiero D, Rosano G, Perrone-Filardi P. A meta-analysis reporting effects of angiotensin-converting enzyme inhibitors and angiotensin receptor blockers in patients without heart failure. Journal of the American College of Cardiology. January 2013. doi:10.1016/j.jacc.2012.10.011 · PMID 23219304
5. Other Ramipril Pregnancy and Breastfeeding Warnings
6. Other Fischer J, Ganellin CR. Analogue-based Drug Discovery. 2006
7. Other British national formulary: BNF 76. 2018
8. Other The Top 300 of 2023
9. Other Ramipril Drug Usage Statistics, United States, 2014 - 2023
10. Journal / agency Pilote L, Abrahamowicz M, Eisenberg M, Humphries K, Behlouli H, Tu JV. Effect of different angiotensin-converting-enzyme inhibitors on mortality among elderly patients with congestive heart failure. CMAJ. May 2008. doi:10.1503/cmaj.060068 · PMID 18458262 · PMC2335176
11. Journal / agency Remuzzi G, Macia M, Ruggenenti P. Prevention and treatment of diabetic renal disease in type 2 diabetes: the BENEDICT study. Journal of the American Society of Nephrology. April 2006. doi:10.1681/ASN.2005121324 · PMID 16565256
12. Journal / agency Chrysochou C, Foley RN, Young JF, Khavandi K, Cheung CM, Kalra PA. Dispelling the myth: the use of renin-angiotensin blockade in atheromatous renovascular disease. Nephrology, Dialysis, Transplantation. April 2012. doi:10.1093/ndt/gfr496 · PMID 21993376
13. Journal / agency Ahmed A. Use of angiotensin-converting enzyme inhibitors in patients with heart failure and renal insufficiency: how concerned should we be by the rise in serum creatinine?. Journal of the American Geriatrics Society. July 2002. doi:10.1046/j.1532-5415.2002.50321.x · PMID 12133029
14. Other Ramipril Side Effects
15. Journal / agency Frampton JE, Peters DH. Ramipril. An updated review of its therapeutic use in essential hypertension and heart failure. Drugs. March 1995. doi:10.2165/00003495-199549030-00008 · PMID 7774515
16. Journal / agency Thomsen R, Rasmussen HB, Linnet K. In vitro drug metabolism by human carboxylesterase 1: focus on angiotensin-converting enzyme inhibitors. Drug Metabolism and Disposition. January 2014. doi:10.1124/dmd.113.053512 · PMID 24141856
17. Journal / agency McCarron D. 24-hour blood pressure profiles in hypertensive patients administered ramipril or placebo once daily: magnitude and duration of antihypertensive effects. Clinical Cardiology. September 1991. doi:10.1002/clc.4960140908 · PMID 1835914
18. Other HOPE Trial: Main Outcomes and Serum Creatinine. 13 August 2001
19. Journal / agency Malmberg K, Rydén L. Ramipril reduced mortality and cardiovascular morbidity in high risk adults. BMJ Evidence-Based Medicine. March 2000. doi:10.1136/ebm.5.2.47
20. Other Jafary F, Yusuf S, Nissen S. Debate: Do ACE Inhibitors Have Unique Properties, Beyond Their Antihypertensive Effect?. 2002
21. Journal / agency Effect of ramipril on mortality and morbidity of survivors of acute myocardial infarction with clinical evidence of heart failure. The Acute Infarction Ramipril Efficacy (AIRE) Study Investigators. Lancet. October 1993. doi:10.1016/0140-6736(93)92693-N · PMID 8104270
22. Journal / agency Yusuf S, Teo KK, Pogue J, Dyal L, Copland I, Schumacher H, Dagenais G, Sleight P, Anderson C. Telmisartan, ramipril, or both in patients at high risk for vascular events. The New England Journal of Medicine. April 2008. doi:10.1056/NEJMoa0801317 · PMID 18378520
23. Other Cis, endo-2-azabicyclo-[3.3.0]-octane-3-carboxylic acids, a process for their preparation, agents containing these compounds and their use

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